Full of Sound and Fury: But does America’s Medicaid debate signify anything for global health? Bi-weekly Checkup (5/10/13)

As developing countries implement (or experiment with) different ways to improve health outcomes and increase access to care, there are a lot of questions about what’s the most effective approach. Unfortunately, here in the U.S., the biggest public health story of the moment has completely failed to provide any answers.

The state of Oregon recently conducted a two-year study on the effects of Medicaid (a federal health insurance program for low-income people) on clinical outcomes. It was a randomized-controlled trial, considered the gold-standard of clinical studies.

That doesn’t exactly sound like the kind of event that would spark a raging controversy. But to the surprise of many, the study found that although Medicaid led to increased access and utilization of health care, this produced no observable reductions in measured blood-pressure, cholesterol, or hemoglobin levels – three of the four outcomes the research measured. (For the fourth outcome, depression, Medicaid coverage did lead to a substantial reduction in the risk of a positive screening.)

The researchers added a number of caveats to their conclusions:

Though the study included over 12,000 people, a relatively small number of them actually had the conditions being assessed

By far the most prevalent of these conditions was depression, the only condition in which they detected improvements

There were improvements in some health measures that weren’t statistically significant, but that would be considered clinically significant

Perhaps most importantly, they also made the following point: “Health insurance is a financial product that is aimed at providing financial security by protecting people from catastrophic health care expenses if they become injured or sick (and ensuring that the providers who see them are paid). In our study, Medicaid coverage almost completely eliminated catastrophic out-of-pocket medical expenditures.”

As the U.S. struggles with skyrocketing medical costs and high public debt, Medicaid has become a political football. And since the program is slated to expand next year under Obama’s Affordable Care Act, it was inevitable that his ideological opponents would use the Oregon study’s results as a cudgel against Medicaid, Obamacare, and government health care interventions in general. It was equally inevitable that his defenders would do their best to spin the results in the opposite direction.

But as the debate has spiraled, it has largely managed to avoid any discussions that could actually improve public health in the U.S., or point toward workable solutions that could apply to other countries. Assuming the study’s results are accurate, here are some obvious follow-up questions:

Is health care in general ineffective at reducing blood pressure, cholesterol and hemoglobin in a two-year period? Or are health care providers that accept Medicaid recipients providing inferior care?

Are there more effective – and less expensive – ways to get patients to make the kinds of lifestyle changes that can improve these conditions?

Are other factors reducing the effectiveness of the care that poor people receive – and if so, how can we address this?

Or are the main effects of public health insurance only measurable over a longer period, or in a larger study group?

In spite of all the sound and fury over the Oregon study, nobody is disputing the fact that access to health care improves health. And public insurance programs like Medicaid clearly increase access to care. Is it the kind of care that low-income people need to maximize their health in the most cost-effective manner possible? If not, what should change? Those are questions worth answering, in the U.S. and around the world. Why aren’t more people asking them?

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